To the best of our knowledge, this is the first study evaluating the impact of health policies on healthcare seeking behaviors, from the perspective of synergic policies to strengthening primary care. 29 Taking advantage of the population-based nationally representative survey before and after 2009, we were able to investigate whether the impacts changed with the progress of the health system reform, in which the two policy areas are evolving simultaneously. Our findings can provide implications for further advancing the agenda of deepening the synergic policies on primary care strengthening, by identifying policy entry points to promote PHC systems from a joint vision.
In this study, several key findings were highlighted. First, increasing health insurance ARR and physician density at PHC institutions were associated with more outpatient visits and admissions and more likelihood of visiting PHC institutions. Previous studies have found that introduction of PHC providers would lead to a shift of care from specialists to primary care for disease management in different settings. 30-34 In addition, studies in Sweden and Mexico have indicated that government financial investment in PHCs increased the number of visits to PHCs. 12,35 The majority of studies have focused on single policies (e.g. health insurance or investment in health workforce). However, few have investigated the efforts in a synergic way which contributed to improving use of PHC of a large proportion of the world’s population. 36 Strengthening primary care requires national actions in multiple interrelated health systems policy areas. 37 Increasing the use of PHC may be dependent on improvements in service delivery, including the management of health workforce, as well as in financing. Recognizing these interdependencies makes the task of designing or reforming systems a complex one, but is critical for a systemic approach to primary care strengthening.
Second, compared to 2008, the positive impacts of health insurance ARR and physician density on increasing outpatient visits and admissions dropped significantly in 2013. Diminished marginal return of increasing health inputs in high-resource-density domains implies better strategies that priorities of health resource allocation need to focus on the resource-poor parts such as the PHC institutions. 38 The findings on comparison in healthcare seeking behaviors between 2008 and 2013 were consistent with previous studies focusing on China’s health system reform, which indicated that the reform with multipartite policies may make interactional impacts on healthcare use. 39 Nevertheless, these previous studies have not assessed the impact of health system reform on healthcare seeking behaviors. Notably, the positive associations with admissions still reminded us with the challenge that a moral hazard situation arises when health insurance coverage is universal, and SHI participants overuse health services especially hospital-based medical services. 40-42 In 2016, the rate of hospital admission in China was 16.4%, higher than the average for countries of the Organization for Economic Cooperation and Development, which implies that China needs to examine the appropriateness of inpatient care, including overuse and misuse of medical services. Therefore, China’s health system reform needs to consider redistributing the existing health resources rather than to continuously increase the health resources, for more effectiveness of financial and service-delivery policy arrangements. A previous study showed the encouraging results that the investment in PHC providers showed largest impact on improving healthcare use 43, so ensuring an adequate availability of PHC providers is one of top priorities to improve the effectiveness of healthcare delivery. Our study provided an evidence-based approach for taking steps towards structural adjustment to tackle the sluggish development of existing policy arrangements. 44
Third, the negative impact of health insurance ARR and physician density at PHC institutions on likelihood of visiting hospitals in 2013 was larger than these in 2008. The results can be explained by the declining use of PHC as a proportion of total health services from 2008 to 2013. Despite the evidence of the progress made in strengthening the PHC system, some challenges remain immense. The physician density at county hospitals was higher than PHC institutions, and had also seen a higher growth, thereby widening the gap of physician density between PHC institutions and hospitals from 2008 to 2013. This unintended result of the reform might lead to the declining use of PHC as a proportion of total health services. The major reason for the unintended results of the reform is the inconsistence of the development of health insurance and health workforce, the two health system policy areas. Although the SHI has achieved a lot in coverage and service benefit, the quantity of PHC providers is inadequate, 9,45 and the incentive mechanism for PHC providers is weak 8.
There are three points on the implementation of policies to explain how the real condition, unlike the policy, are related to the findings of the study. First is the zero-profit medicine policy. 6 Although local governments increase the budgets to balance financial loss of PHC institutions from drugs benefits, this part of financial support is dependent on local government’s financial capacity and cannot make up the loss in most of cases. 46 There are many complaints about the unavailability of essential drugs on the list of the SHI, that pushes patients to be referred to hospitals and restricts the professional development of PHC providers. 47 Although the SHI has achieved a lot in coverage and service benefit, the limitation of essential drugs covered by the SHI can lead patients bypass PHC institutions to seek health services at high-level hospitals. Second is the financial arrangements for PHC institutions with the delink between revenue and expenditure. The revenues obtained by providing PHC should be turned over to the government financial accounts, and the expenditures incurred are financed according to the standards designed by the government financial department. 7 The delink between revenue and expenditure reduced the financial incentives for PHC providers because their income is fixed and has nothing connection with the workload of providing PHC. 46 However, the fee-for-service payment system in hospitals gives hospitals an incentive to attract and retain patients who could otherwise use PHC providers. 9 Third is the salary reform for PHC providers. The percentage of performance-based bonus on the total income is quite low, limiting the financial incentives for providing PHC. 8 The consequent lack of motivation has led to a brain drain to hospitals and out of the health system altogether. 48 In 2017, only 13% of PHC providers had a formal medical education (five years of medical school) in rural and 40% in urban areas. 10 In a word, efforts to cope with the capacity strengthening PHC system have been slow, mostly because of insufficient coordination and fragmented systems. 49,50
Since quality of care given by PHC providers is still unsatisfactory, patients in real needs choose to bypass the PHC system in favor of hospitals, which resulted in soaring cost of medical care. 51 The synergic policies that are issued to tackle access to healthcare and financial protection have not succeed, even further lower the affordable accessibility of the low-income group. Therefore, further reforms should consider transforming the existing hospital-centered healthcare system to an integrated health system based on PHC in a systemic way. A competent health workforce is indisputably important, and a good financing system including effective incentive mechanisms for PHC providers should continue to focus on aligning incentives for providing quality PHC. 52 Strengthening platforms to design and implement more effective multisectoral actions is urgently required. This can include the development of national whole-of-government multisectoral plans, establishing mechanisms for coordination across ministries and other stakeholders, and multi-sectoral mechanism at the stage of monitoring and evaluating enforcement of policies. 53
This study has several limitations. First, the observational nature of our study limited our ability to draw any causal inference from our findings. Rather, the association found in this study underscored the need for research to evaluate the progress of the synergic policies on primary care strengthening from the perspectives of health financing and health workforce. Second, only the 2008 and 2013 round of NHSS were included to evaluate the five-year progress of health system policies. This mid-term impact assessment might limit us to generate policy relevance. Although we did not have data of the latest 2018 round of NHSS which has not been open for analysis, it was reported that healthcare seeking behavior sustained the trend and the health insurance coverage and physician density continued to be improved during 2013 and 2018. 9,11 Nonetheless, this interim impact analysis might make our estimates of the associations between health insurance and health workforce and healthcare seeking behavior conservative.